What Kind of EHR Would Sully Design?

I was there, March 4th in Atlanta, to hear Captain Sullenberger speak at the HIMSS conference about patient safety. It was more than just a great speech; it was a tour de force. His first speech post-retirement, the question and answer period included “thank you”s, questions, comments, and personal accounts that were, at turns, grateful, angry (at systemic problems), and inspired (and in one case, tearful).

Keynoter Captain Chesley “Sully” Sullenberger at HIMSS
(26x zoom from the rear of the hall!)

I meant to post this account immediately, post HIMSS, but I found that I simply wasn’t ready to do so. It made me think that much. I didn’t want to post until my ruminations about what he said had settled, though I’ll save my personal and professional reactions for a later post. I will note here that Captain Sullenberger has a graduate degree in Industrial Psychology from Purdue, with a concentration in human factors, a frequent topic of this blog as it relates to EMR usability.

That I waited may be serendipitous. The issues Captain Sullenberger addressed, including the relationship between EMR usability and patient safety, are more hotly debated now than at any time previously.

Nota bene, while I am a pretty good note taker, I am not a professional stenographer. The following are my paraphrases of a subset of Captain Sullenberger’s remarks, the subset that seemed most relevant to combined issues of EMR usability, medical error, and patient safety. Phrases in bold are my emphasis. I’ll likely return to them in a future post.

Captain Chesley “Sully” Sullenberger began:

I seem to have become the public face of a remarkable event

it was really a story of preparation, teamwork, and initiative that saved the day

in these thirty years my profession has evolved in ways that other professions may not have had to

both aviation and medicine are high stakes endeavors

today I ask this question, could the practice of medicine become as safe as aviation has become? What would make that possible?

what methods can we take from my industry and my domain and be applied to the field of medicine

we have learned a lot which we are anxious to share with you

all electronic systems must be made simple and intuitive to the user that has to use them and it is important that the end users be involved in their design from the very beginning

a complicated system that for example requires the user to click forty boxes…or one that blasts a bright alert for every minor problem does not add value, in fact such complicated systems can create more safety problems than they solve

in addition to expanding our ability to collect and share information aviation began to focus on improving human performance in the 1980’s with crew resource management, or CRM

because we are all fallible humans we need a system to ensure that we do every step every time

aviation has many complex systems and medicine has many more, relying on human memory to navigate them is untenable

in aviation we have evidence-based checklists to help us cross-check that killer items have been complete properly every time

a check list is not just a piece of paper, what makes a check list effective is not even the words on that piece of paper, what makes it effective is discipline, the attitude, the behaviors that go along with it

a check list promotes teamwork, creates a share sense of responsibility, formalizes best practices, encourages two-way communication, requires effective leadership and followership…who knew that a piece of paper could do all that

some professionals worry that relying too heavily on checklists will turn them into procedural robots

But that’s simply not true

paradoxically strong procedural competence … gives you the flexibility to face the unexpected

I always knew that there couldn’t be a checklist for everything and that there is no substitute for experience

I know that some in the medical field take issue with equating aviation with medicine

planes are not as sick as some of their patients and while it is true that medicine operates with less certainty than aviation we deal with more uncertainty than is generally recognized

just as in manufacturing automobiles where quality must be designed in and built in not inspected in afterward

In aviation and in medicine safety usability must be designed and built into the very fabric of the process not inspected in after the fact

safety is too important to be managed by exception

after 75 years [aviation] has benefits from lessons learned at great cost, literally bought in blood, lessons we know offer up to the medical profession for the taking

accidents are hardly ever the result of a single cause, but the last link in a causal chain

I am hopeful you will make these changes in the field of medicine, If you do ultimately it will be for three reasons, your patients deserve it, your colleagues expect it, your profession demands it

My question to you, and me, is:

What Kind of EMRs, EHRs, and Clinical Groupware Would Captain Sullenberger Design?